title: Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a "poor man's epidural".
abstract: BACKGROUND
  The epidural route is still considered the gold standard for labour analgesia, although it is not without serious consequences when incorrect placement goes unrecognized, e.g. in case of intravascular, intrathecal and subdural placements. Until now there has not been a viable alternative to epidural analgesia especially in view of the neonatal outcome and the need for respiratory support when long-acting opioids are used via the parenteral route. Pethidine and meptazinol are far from ideal having been described as providing rather sedation than analgesia, affecting the cardiotocograph (CTG), causing fetal acidosis and having active metabolites with prolonged half-lives especially in the neonate. Despite these obvious shortcomings, intramuscular and intravenously administered pethidine and comparable substances are still frequently used in delivery units. Since the end of the 90 ths remifentanil administered in a patient-controlled mode (PCA) had been reported as a useful alternative for labour analgesia in those women who either don't want, can't have or don't need epidural analgesia.
  
  
  CONCLUSIONS
  In view of the need for conversion to central neuraxial blocks and the analgesic effect remifentanil has been demonstrated to be superior to pethidine. Despite being less effective in terms of the resulting pain scores, clinical studies suggest that the satisfaction with analgesia may be comparable to that obtained with epidural analgesia. Owing to this fact, remifentanil has gained a place in modern labour analgesia in many institutions. However, the fact that remifentanil may cause harm should not be forgotten when the use of this potent mu-agonist is considered for the use in labouring women. In the setting of one-to-one midwifery care, appropriate monitoring and providing that enough experience exists with this potent opioid and the treatment of potential complications, remifentanil PCA is a useful option in addition to epidural analgesia and other central neuraxial blocks. Already described serious consequences should remind us not refer to remifentanil PCA as a "poor man's epidural" and to safely administer remifentanil with an appropriate indication.
  
  
  CONCLUSIONS
  Therefore, the authors conclude that economic considerations and potential cost-savings in conjunction with remifentanil PCA may not be appropriate main endpoints when studying this valuable method for labour analgesia.
authors.affiliation: Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, Oberdürrbacher Str. 6. Würzburg 97080, Germany. kranke_p@klinik.uni-wuerzburg.de
authors.forename: Peter
authors.initials: P
authors.lastname: Kranke
authors.forename: Thierry
authors.initials: T
authors.lastname: Girard
authors.forename: Patricia
authors.initials: P
authors.lastname: Lavand'homme
authors.forename: Andrea
authors.initials: A
authors.lastname: Melber
authors.forename: Johanna
authors.initials: J
authors.lastname: Jokinen
authors.forename: Ralf M
authors.initials: RM
authors.lastname: Muellenbach
authors.forename: Johannes
authors.initials: J
authors.lastname: Wirbelauer
authors.forename: Arnd
authors.initials: A
authors.lastname: Hönig
mesh_terms: D015360:Analgesia, Epidural / Q000191:economics; D016058:Analgesia, Patient-Controlled / Q000191:economics; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D005260:Female; D006801:Humans; D007743:Labor, Obstetric; D009609:Nitrous Oxide / Q000008:administration & dosage; D059408:Pain Management / Q000191:economics / Q000379:methods*; D010880:Piperidines / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D011247:Pregnancy; D000077208:Remifentanil
chemical_list: D000701:Analgesics, Opioid; D010880:Piperidines; D009609:Nitrous Oxide; D000077208:Remifentanil